The healthcare sausage factory

Some in the Republican party refuse to discuss the merits of healthcare reform [EPA]

Watching healthcare reform legislation pass through the US Congress is like watching sausage get made. It is a gory and lumbering process of alliances and amendments, procedure and pandering.

The full sausage factory was put on display this year as the Obama administration's top domestic priority, healthcare reform legislation, made its way through the House of Representatives and Senate.

The global fascination with the twists and turns of the legislative process attest to the importance of the issue to the US president and the future of America's most vulnerable citizens.

The landmark vote in the House over the weekend is the most recent step in the sausage-making process. It has taken 100 years since healthcare reform was first mentioned to get to the point where a bill might possibly become law.

Members of the House passed by 220-215 a bill that would extend coverage to 36 million Americans (leaving about 12 million illegal immigrants without coverage) and cost about $1tn.

Debate and negotiations

Next, the US Senate will put out their version of a healthcare reform bill for debate, likely in the next couple of weeks. And then, if that bill passes, it will be reconciled with the House version, the most difficult phase of the process.

A committee of House and Senate negotiators will extrude parts of both bills, merging them into one bill. Then it is back to their chambers for a final vote. Only then can the legislation be signed into law by the president.

Over the summer, Barack Obama expressed confidence in the process: "We are going to get this done. Inaction is not an option."

Since then he has continued to press the Democratic leadership in Congress to get something ... anything, to him by the end of the year. The Senate fight will be a lot tougher than the House. Debate could take weeks, compared to the House's four hours.

Considering the Thanksgiving and Christmas holidays are coming up, it leaves Congress only about four-and-a-half weeks of time in session to complete the process. And Congress never met a deadline it could not miss. So if healthcare reform is to pass this year, it will be very tight.

Down to the wire

Obama will face a tougher fight in the Senate than in the House of Representatives [EPA]

The final bill will likely pass or fail by one or two votes because the Democrats retain a Senate majority in name only.

They form more of a weak coalition than a voting bloc. There are Democratic sceptics who do not like the idea of a government-sponsored health plan, those who cannot stomach the likely trillion-dollar price tag, and those who object to the bill's provisions on funding for abortion.

The Republicans as a political party are irrelevant to the healthcare debate now; they have proved that they are unwilling to consider the proposal on its merits and offer suggestions.

When the House bill passed, John Boehner, the House Republican leader, said: "I came here to fight big-government monstrosities like this bill that dim the light of freedom and diminish opportunity for future generations."

Despite the feelings of most Republicans in Congress, there may be one or two who could prove vital to passing the legislation in the Senate, but only because they do not think like the rest of their party. But really this is a war Democrats are waging against each other.

Antithesis of Clinton?

Obama has been mute on the specific details he would like to see in a healthcare reform bill. His political strategy seems to be to do exactly the opposite of what Bill Clinton, the former US president, tried in 1993. Clinton demanded a specific set of reforms, which his wife presented to Congress.

But they balked at being told how to legislate by a new president, and the effort famously went down in flames over the objections of doctors, hospitals and pharmaceutical companies. Obama has spent the last several months getting those same interest groups on board with at least some of the proposed reforms.

All he manages to say about any proposed reform is that it must ensure "choice and competition".

If the arduously slow sausage-making process goes as Obama and the Democratic leadership anticipates, the final product that makes it to the president's desk for his signature will not be comprehensive coverage for everyone in the US.

Nothing that is being considered now would make the system any less complicated for those people already using the healthcare system.

And for those Americans who would finally get coverage, they will gain access to a complicated, unwieldy system of different plans and levels of coverage peppered with insurance company denials.